| Dental Cleaning - Adult | $96 | 0% | $96 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $164 | 0% | $164 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $272 | 0% | $272 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $218 | 0% | $218 |
Medium |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
Medium |
| Maintenance Therapy - Periodontal | $145 | 0% | $145 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $170 | 0% | $170 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $112 | 0% | $112 |
Medium |
